Physical Signs, Symptoms, Diagnosis and. Differential Diagnosis in Clinical Medicine. SN Chugh. Ashima. Clinical Medicine. Differential Diagnosis in

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1 Physical Signs, Symptoms, Diagnosis and Differential Diagnosis in Clinical Medicine Salient features of the book It details the symptoms of a disease pertaining to systems, does the symptom analysis so as to pick up the specific system to which the symptom pertain. Examination (general, physical and systemic) concentrates on the detection of physical signs, and their interpretation, so as to narrow down the diagnostic possibilities. Diagnosis is made provisionally based on physical signs but is confirmed by diagnostic tests. The differential diagnosis is mostly made on the physical signs so to avoid unnecessary diagnostic tests. The book emphasizes the importance of physical signs in the diagnosis and differential diagnosis. Nowadays physicians/students rely more on the investigations than the physical signs, hence advise a large battery of tests which consume time as well as money. At the end of each unit, brief synopsis of various diseases pertaining to different systems is provided. The book is more or less complete as far as diagnostic symptoms and signs are concerned. It is written in a simple understandable language. The present day students do not want to learn medicine in detail but just aim to pass the examination; they are always in search of good books which can provide them ready-made material. The authors have written this book keeping such readers in view. SN Chugh MD, MNAMS, FICP, FIACM, FICN, FISC, FIMSA is former Senior Professor of Medicine, Pt BD Sharma Postgraduate Institute of Medical Sciences, and also Pro Vice-Chancellor, Pt BD Sharma University of Health Sciences, Rohtak, Haryana. Prof Chugh has a vast experience of more than 40 years in teaching the subject of medicine to medical and dental students, both at undergraduate and postgraduate levels. He has written 13 books in the field of medicine for medical students, nurses and paramedical personnel, and contributed a chapter in API Textbook of Medicine, 8/e. Ashima MBBS (Gold Medalist), MD is ex-senior resident, GB Pant Hospital, New Delhi. ISBN: Physical Signs, Symptoms, Diagnosis and Differential Diagnosis in Clinical Medicine Chugh Ashima Physical Signs, Symptoms, Diagnosis and Differential Diagnosis in Clinical Medicine SN Chugh Ashima CBS Publishers & Distributors Pvt Ltd 4819/XI, Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi , India delhi@cbspd.com, cbspubs@airtelmail.in; Website: New Delhi Bengaluru Chennai Kochi Kolkata Mumbai Hyderabad Jharkhand Nagpur Patna Pune Uttarakhand CBS Publishers & Distributors Pvt Ltd

2 Physical Signs, Symptoms, Diagnosis and Differential Diagnosis in Clinical Medicine

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4 Physical Signs, Symptoms, Diagnosis and Differential Diagnosis in Clinical Medicine S N Chugh MD, MNAMS, FICP, FIACM, FICN, FISC, FIMSA Ex-Senior Professor of Medicine Pt BD Sharma PG Institute of Medical Sciences and Ex-Pro Vice Chancellor Pt BD Sharma University of Health Sciences Rohtak, Haryana Ashima MBBS (Gold Medalist), MD ex-senior resident, GB Pant Hospital New Delhi CBS Publishers & Distributors Pvt Ltd New Delhi Bengaluru Chennai Kochi Kolkata Mumbai Hyderabad Jharkhand Nagpur Patna Pune Uttarakhand

5 Disclaimer Science and technology are constantly changing fi elds. New research and experience broaden the scope of information and knowledge. The authors have tried their best in giving information available to them while preparing the material for this book. Although all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected. The publisher, the printer and the authors will not be held responsible for any inadvertent errors or inaccuracies. Physical Signs, Symptoms Diagnosis and Differential Diagnosis in Clinical Medicine ISBN: Copyright Authors and Publisher First Edition: 2017 All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission, in writing, from the authors and the publisher. Published by Satish Kumar Jain and produced by Varun Jain for CBS Publishers and Distributors Pvt Ltd 4819/XI Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi , India. Ph: , , Fax: Website: Corporate Offi ce: 204 FIE, Industrial Area, Patparganj, Delhi , India Ph: Fax: Branches Bengaluru: Seema House 2975, 17th Cross, K.R. Road, Banasankari 2nd Stage, Bengaluru , Karnataka, India Ph: /79 Fax: Chennai: 7, Subbaraya Street, Shenoy Nagar, Chennai , Tamil Nadu, India. Ph: , Fax: Kochi: Ashana House, No. 39/1904, AM Thomas Road, Valanjambalam, Ernakulam , Kochi, Kerala, India. Ph: Fax: Kolkata: 6/B, Ground Floor, Rameswar Shaw Road, Kolkata (West Bengal), India. Ph: , , Mumbai: 83-C, Dr E Moses Road, Worli, Mumbai , Maharashtra, India. Ph: /41 Fax: mumbai@cbspd.com Representatives Hyderabad Jharkhand Nagpur Patna Pune Uttarakhand Printed at: NewTech Printer, Faridabad, India.

6 Preface It gives us immense pleasure to introduce the first edition of our book entitled Physical Signs, Symptoms, Diagnosis and Differential Diagnosis in Clinical Medicine to medical students and physicians. In the present era of high profile sets of investigations, the physical signs occupy the back seat. Physicians rely more on investigations than the physical signs forgetting that they are clues to diagnosis. Investigations are planned based on provisional diagnosis/differential diagnosis. Mind thinks about what you see, therefore, we should not forget the significance of physical signs. A student/physician after taking the detailed history, analysing the symptoms, interprets the physical signs and comes to some physical diagnosis. After critical analysis of the signs, he/she narrows down the differential diagnosis and then plan the investigations. Missing or misinterpretation of physician signs can point to erroneous diagnosis. Therefore, we have introduced this book for picking up correct clinical signs and interpret them correctly to give correct provisional diagnosis/differential diagnosis. The book has been written on the request of our students and younger teachers, so as to apprise the students, about the clinical significance of physical symptoms and signs. A large number of books are available on clinical examinations but some lack in substance while others lack in the analysis of symptoms/signs clues to diagnosis/differential diagnosis. This book gives you detailed analysis of symptoms pertaining to various systems, their analysis and the detailed physical signs to highlight the diagnosis and differential diagnosis. At the end of each unit, brief synopsis of various diseases/conditions is provided for viva voce at the bedside. We think this book will cater the need of the students and physicians and they would like it for making prompt spot provisional diagnosis. We are thankful to CBS Publishers who have provided me the opportunity to introduce this book and we are happy that they have brought a colourful edition of this book. SN Chugh Ashima Chugh

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8 Contents Preface UNIT I General Physical Examination 1 General Physical Examination 1 Head (Cranium) 4 The Eye Examination 6 Examination of Ear, Nose, Throat 8 The Neck 17 Regional lymphadenopathy 18 The Breast and Axillae 20 The Extremities 20 UNIT II Examination of Respiratory System 29 Respiratory System 29 Symptoms related to Upper Respiratory Tract and their Analysis 29 Symptoms of Lower Respiratory Tract and their Analysis 31 History 36 General Physical Examination of Respiratory System 36 Examination of Upper Respiratory System 39 Examination of Lower Respiratory System (Chest examination) 41 Adventitious/Added Sounds 54 Examination of the Posterior Chest 58 Differential Diagnosis 59 Brief Synopsis of Common Respiratory Diseases 59 UNIT III Cardiovascular System 71 Symptoms and their Analysis 71 The History 77 General Physical Examination 78 Systemic Examination of Cardiovascular System 89 Differential Diagnosis of Murmurs 101 I. Ejection Systolic (ES) or Midsystolic Murmur 102 II. Pansystolic Murmurs 104 Diastolic Murmurs 105 Continuous Murmurs 107 Physical Signs of Different Cardiovascular Conditions 108 Peripheral Vascular System 115 Examination 116 Brief Synopsis of Peripheral Vascular Disease 120 The Venous System 122 Brief Synopsis of Venous Disorders 122 UNIT IV The Urogenital System and Sexually Transmitted Diseases 127 I. Common Urinary Symptoms and their Analysis 127 II. Symptoms of Sexually Transmitted Diseases (STDs) 133 The History 133 Examination General Physical and Urogenital System (Abdomen Examination) 135 Examination of The Male Genitalia 139 The Scrotum and its Contents 141 Differential Diagnosis of a Scrotal Swelling 143 Examination of Female Genitalia 143 Brief Synopsis of Common Renal Disorders 146 Brief Synopsis of Genital Diseases and Hernia 149 UNIT V Nervous System 153 Common Symptoms and their Analysis 153 History 161 Examination General Physical 162 v

9 viii Physical Signs, Symptoms, Diagnosis and Differential Diagnosis Systemic Neurological Examination 170 Mental Status/Higher Mental Functions 170 Speech and Language 172 Examination of Cranial Nerves 176 The Motor System Examination 203 Testing for the Cerebellar Functions 222 Gait 225 The Sensory System 234 Nerve lesion (Entrapment Neuropathy) 242 Autonomic Nervous System (ANS) 243 Nervous System at a Glance 246 Brief synopsis of the Neurological Disorders 247 Epilepsies 252 Polyneuropathies 252 Postinfective Polyneuropathy (Guillain-Barré syndrome) 253 Myasthenia Gravis 254 Multiple Sclerosis 254 Syringomyelia 255 Motor Neuron Disease (MND) 255 Paraplegia 256 UNIT VI Gastrointestinal and Hepatobiliary Systems 257 Symptoms of Gastrointestinal System 257 Symptoms of Hepatobiliary System 268 History 271 Examination General Physical and Systemic (Abdominal examination) 271 Examination of Inguinal Region 292 The Back of Abdomen 292 Examination of the Anus, Rectum and Prostate 292 Examination of Abdominal Lump/Mass 294 Brief synopsis of common GI Tract Hepatobiliary Disorders 299 UNIT VII Examination of Breasts and Axillae 313 Common Symptoms Related to Breast 313 Examination of Breasts 316 Brief Synopsis of Breast Diseases 319 UNIT VIII Haematological Disorders 321 Pattern of Haematological Disorders 321 History 331 Examination of a Patient with Haematological Disorder 332 Systemic Examination 337 Brief Synopsis of Common Blood Disorders 337 Laboratory Diagnosis of Hematological Disorders 342 UNIT IX Endocrinal Disorders 347 Symptoms of Endocrine System 347 History 348 General Physical Examination (GPE) 349 Systemic Examination 357 Brief Synopsis of Endocrinal Disorders 357 UNIT X Examination of Musculoskeletal and Locomotor System 371 Major Symptoms of Rheumatic Diseases 371 History 376 Examination of Locomotor System 377 Examination of Individual Joints 380 Examination of the Spinal Column 385 Examination of Limb Joints 389 Brief synopsis of Rheumatological disorders 401 UNIT XI Dermatological Disorders 407 Symptoms of Skin Disorders and thier Analysis 407 History 408 Examination General 410 Examination of Nails 419 Examination of Hair 420 Brief synopsis of Common Skin disorders 420 UNIT XII Vitals and the Unconscious Patient 427 Symptom Unconsciousness 427 History 428 Examination General Physical 429 Systemic Examination 433 Other Systems Examination 438 Brief Synopsis of Different Comas 438 Index 445